Unit Clerk

Maintain medical records in accordance with federal and state guidelines, as well as in accordance with our established policies and procedure. Acts as clerk on the Nursing Units to assist in all non-professional task and duties.

Delegation of Authority

As Unit Clerk, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Job Functions

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

Duties and Responsibilities

Administrative Functions

• Is the custodian of medical records to include coding,
• auditing of discharged records and insuring completion of same.
• Prepare and set up for all new admissions and update information as needed.
• Deletes forms when indicated and maintains all residual files. Follows chart audit/ deletion policy.
• Responsible for quality assurance of closed and open medical records.
• Logs all admissions, discharges, and transfers of residents.
• Reviews all monthly vital signs for completeness and documents in chart.
• Collect charts, assemble them improper order, and inspect them for completion
• Retrieve medical records when requested by procedure
• Reviews all monthly vital signs for completeness and documents in chart.
• Monthly - monitors all Treatment Administration Records, Psychotropic Medication Records, and Medication Administration Records for completeness and then files them in resident’s medical record. Determines what signatures are missing and contact appropriate staff member to complete.
• Check for correct name and room number on all sheets and put heading on as necessary.
• Place appropriate sticker on charts, i.e. DNR, Allergies, Advance directives etc.
• Arrange storage of supply in a neat and orderly fashion on unit.
• Keeps stock forms well supplies in drawers in alphabetical order.
• Keep CNA book up to date.
• Pick up mail from mailbox for both units.
• Order office supplies and maintain par level.
• Answer phone on unit and identify self. Takes messages accurately and transcribes legibly.
• Street clothes are neat and clean at all times, not be confused with Nurses Aide’s.
• Covering for the nursing secretary at the front desk her lunch break.
• Covering for central supply/staffing coordinator during her absent.
• Be available to the unit managers when necessary.
• Other duties as assigned by the Director of Medical Records.

Experience

• Must have at least 3 month(s) experience in a clerical position, or successfully completed a secretarial science program from an accredited school/college.
• Must have computer skills and customer service skills